Review Article

Breast Care 2021;16:559–573 Received: May 27, 2021

Accepted: August 11, 2021
DOI: 10.1159/000518992 Published online: September 16, 2021

Innovative Standards in Oncoplastic

Breast Conserving Surgery: From Radical
Mastectomy to Extreme Oncoplasty
Guldeniz Karadeniz Cakmak
Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey

Keywords the perfect union of science with art. Nevertheless, at the

Oncoplastic surgery · Quality of life · Outcome · Cosmesis · very end, the question is not the nature of the surgeon/artist
Complication · Innovation who would be the extremist, the innovator, or the conserva-
tive, but the patient’s satisfaction, prognosis, and QOL that
conclude the cascade of state of the art of OBCS.
Abstract © 2021 S. Karger AG, Basel
Background: Oncoplastic breast conserving surgery (OBCS),
which is the current procedure of choice for eligible BC pa-
tients, describes a philosophy that prioritizes oncologic and Introduction
cosmetic outcomes. However, knowledge gaps regarding
training, acceptance, and practice preclude standardization Algorithms proved to be the standard of care to treat
and make it difficult to design algorithmic guidelines to op- breast cancer (BC) and have evolved tremendously over
timize individualized management in the era of precision the last century. After the evidence-based medicine con-
medicine. Summary: The harmony between patient expec- firmed that BC is a heterogenous spectrum of diseases
tations and oncologic goals creates the state of the art of differing individually and loco-regional control is not
OBCS. Nevertheless, to achieve these goals, multidisciplinary solely a function of disease burden, but tumor biology
approach is a must. Surgical decisions require a comprehen- and effective systemic therapy that counts more, onco-
sive evaluation including patient factors, tumor biology, ge- plastic breast conserving surgery (OBCS) has entered the
netics, technical considerations, and adjunct therapies. arena of BC surgery as a novel concept in mid-1980s with
Moreover, the quality-of-life (QOL) issues should be consid- promising outcomes regarding oncologic safety, cosmet-
ered as the highest level of priority with a shared decision ic acceptability, and patient satisfaction. The term OBCS
making instituted on realistic discussions with the patient. describes a philosophy that prioritizes both oncologic
Key messages: The standardization in OBCS should be initi- and cosmetic outcomes. Accordingly, OBCS is not a new
ated via defining a breast surgeon who should gain theorical approach, but the question is the global variability in
and practical competence on techniques via national or in- training, awareness, and clinical practice, creating issues
ternational educational programs. The algorithmic patient about standardization to allow comparative scientific re-
assessment with appropriate documentation before and af- search and to design algorithmic guidelines to optimize
ter surgery should be established. A simple and safe global individualized surgical management in the era of preci-
lexicon should be designed regarding techniques to be pro- sion medicine which we aimed to address in the present
posed and quality metrics to be considered. Additionally, in- review. In addition, it is critical to embrace oncoplastic
ternational multicenter prospective trials should be institut- philosophy from every perspective of multidisciplinary
ed to overcome knowledge gaps. It is evident that OBCS is approach since margin-negative tumor resection, opti-

karger@karger.com © 2021 S. Karger AG, Basel Correspondence to:

www.karger.com/brc Guldeniz Karadeniz Cakmak, gkkaradeniz @ yahoo.com
mal case-based partial breast reconstruction, and adju- mastectomy [9, 10]. The lower local recurrence rates
vant radiation therapy are individually crucial to improve when compared to NASBP-06 were most likely due to
oncologic and aesthetic outcomes. changes with modern medicine with improved patholo-
gy, local therapies, and systemic therapies. From 1985 to
date, we know that the outcome of mastectomy is not su-
The Ages up to OBCS: Historical Perspective perior to BCS with radiation which became one of the
first steps in the innovation of OBCS. However, the mas-
The surgical oncologic journey of BC management tectomy trends in the US increased by 34% from 2003 to
was initiated in 1894 by William Halsted with the defini- 2011 and the rate was highest in the noninvasive and
tion of the radical mastectomy, one of the most extensive node-negative early-stage breast disease. From 1998 to
surgical en-bloc excisions, not only removing the whole 2011, the reconstruction rate also increased from 11.6 to
breast but chest wall muscles along with complete axillary 36.4%, and the rates of bilateral mastectomy for unilat-
nodes with a cure rate of less than 15% [1]. Halstedian eral disease reached 11.2% from 1.9% [11]. The reasons
philosophy has been the preferred option until Bernard behind this are vague and might be attributed to the fear
Fisher entered the modern era of BC management. In of adjunct treatments, anxiety about recurrence, social in-
1957, the National Surgical Adjuvant Breast and Bowel fluences, or poor cosmesis. Accordingly, the term over-
Project (NSABP) was established, and the clinical trials treatment referring to the choice of such a radical ap-
designed by this collaboration shed great valuable light on proach for patients in an early stage and unilateral disease
BC management leading to a major paradigm shift to- without higher genetic risk is the topic of hot discussions,
wards more conservative approaches. Halsted’s doctrine and oncoplastic approaches overcoming the anxiety be-
advocating radical surgery to treat BC was challenged by hind the choice of overtreatment is strongly encouraged.
Fisher’s evidence-based data arguing BC is a systemic dis- ANTHEM feasibility study from UK aiming to compare
ease, so more extensive local resections are unlikely to clinical and patient-reported outcomes (PROs) of level II
provide cure or improve survival of patients. This hy- OBCSs as an alternative to mastectomy and ipsilateral
pothesis was tested via the NSABP-B04 study which was breast reconstruction for patients not eligible for conven-
designed to compare radical mastectomy with mastecto- tional conservation is in progress to answer this question
my and radiation [2]. The results up to 25 years after [12].
treatment revealed no difference in terms of disease-free
survival (DFS), distant disease-free survival (DDFS), and
overall survival (OS), confirming an extensive operation What Is OBCS?
did not improve outcome in node-negative and -positive
patients [3, 4]. The local recurrence rates were better for In traditional BCS, the major issue is the poor cosmet-
patients who had irradiation, and again radical mastec- ic outcomes after irradiation reported up to 30% [13].
tomy was not superior to total mastectomy and radiation There are significant retraction, scarring, deformity, and
therapy, which means radiation provided a better local asymmetry associated with BCS, which is unacceptable
control than extensive surgery [2–4]. Moreover, in the for women. They lead to disturbing quality of life (QOL)
NSABP-06 trial, which accumulated patients from 1976 and to psychiatric disturbances including feeling sexual
to 1984, they examined if there were opportunities to do inadequacy and reluctancy. The synergistic combination
less than total mastectomy. BC patients with tumors of oncologic and aesthetic concepts in a multidisciplinary
smaller than 4 cm either node negative or positive were manner to solve the innate conflict between the goals of
divided into three groups. The first group had modified providing negative margins at the index procedure to
radical mastectomy, the second group had lumpectomy lower risk of recurrence/reexcisions and improved cos-
with axillary lymph node dissection (ALND) without ir- mesis with patient satisfaction has been defined more
radiation, and the last group had lumpectomy with ALND than 2 decades ago as initial aims of OBCS techniques
and radiation therapy [5]. The results of this trial up to 20 [14–16]. OBCS was proposed as a “hybrid” technique in-
years showed no significant difference regarding DFS, volving reconstructing the area of resection via two es-
DDFS, and OS [5]. In accordance, randomized clinical sentially different procedures namely, volume replace-
trials from Europe by Veronesi and colleagues, the Dan- ment and volume displacement techniques [17, 18]. Since
ish group, and EORTC provided evidence revealing then, there has been a great enthusiasm on more ad-
equivalent DFS and OS between mastectomy and breast vanced methods with promising aesthetic and patient-
conserving surgery (BCS) [6–8]. Since these landmark reported QOL outcomes [19, 20]. Nevertheless, the stan-
trials, probably due to the progress in systemic therapies, dardization should begin with nomenclature. The first
more recent observational studies emphasized the com- pronunciation of oncoplasty came from Europe by Au-
parable or even improved survival for BCS relative to dretsch et al. [14] and Clough et al. [21]. Until now, there

560 Breast Care 2021;16:559–573 Karadeniz Cakmak

DOI: 10.1159/000518992
have been various definitions in the literature with a con- to avoid unpredictable outcomes regarding breast shape,
sensus on basic forms, one of which is “the integration of size, symmetry, contour deformities, and nipple areola
plastic surgery techniques for partial or complete recon- complex malposition. IMPORT LOW which is a ran-
struction of the breast mound or correction of surgical domized clinical trial comparing whole breast, partial
defects after resection,” and the most recent one is, “in- breast, and lower doses of irradiation demonstrated that
corporating an oncologic partial mastectomy with ipsilat- alterations in breast appearance was the most common
eral defect repair using volume displacement or volume side effect in approximately 20% of cases showing consis-
replacement techniques with contralateral symmetry sur- tence over time [26]. Another issue to be considered
gery, as appropriate” [22, 23]. However, the functional about whole breast radiation-induced side effects is the
definition is more dynamic and accommodating a phi- breast cup size and standard fractionation which have
losophy, which includes multiple variables to achieve op- been connected to breast shrinkage because of fibrosis
timal result in each individual case linked to patient, tu- and atrophy [27, 28]. This is an area of interest and the
mor, and physician. The first question is the eligibility of mechanisms that could be affected particularly in the set-
breast conservation. If the answer is positive then the cas- ting of OBCS could be clarified via further trials. From
cade begins with meticulous initial assessment of pa- this point of view, it is rational to mention Erasmus’s
tient’s morphology, breast anatomy and glandular den- phrase which is “prevention is better than cure.” OBCS is
sity, continues with tumor size and in-breast location, not only to replenish the defect area of the volume resect-
tumor-breast size ratio, patient’s expectations regarding ed to avoid deformity, to perform a reduction mammo-
the functional and cosmetic outcome, comorbidities, plasty to achieve the breast size appropriate for radiother-
possible adjuvant treatments, and ends up with the exis- apy, to create symmetry in the contralateral breast for rea-
tence of adequate training and expertise of breast surgeon sons of cosmesis, but to improve QOL of each case and to
on OBCS. The oncoplastic surgeon considers each com- provide choices without harassing physical, psychiatric,
ponent precisely to design the best-matched individual- and sexual health. A precise discussion of oncoplastic al-
ized surgical approach meeting both endpoints of pa- ternatives with patients, including PROs of each choice
tient’s needs and oncologic goals before the initial inci- and the risks of complications, is the cornerstone in the
sion at the index procedure. decision making of surgical oncologic management. In
the literature, similar complication rates for OBCS rela-
tive to CBCS have been revealed, except for delayed
Goals of OBCS wound healing favoring CBCS [29, 30]. Additionally, the
surgeon’s main responsibility is to present all surgical op-
The incorporation of oncoplastic philosophy to tradi- tions available and appropriate for individual case in an
tional breast conservation can serve many oncologic and unbiased manner, allowing patient to consider the advan-
cosmetic objectives. The major goal is to achieve patient’s tages and disadvantages of proposed operations and de-
well-being and satisfaction with improved aesthetic out- cide accordingly between breast conservation or mastec-
comes when compared to conventional techniques. With tomy which would make feel more supported and im-
strict compliance to oncologic principles, the aims of OPS prove compliance to treatment. There are other
are defined as the complete excision of the tumor with well-established goals of OBCS, one of which is to offer
margin negativity, preferably in a single step operation the potential to expand the applications of conservation
with the lowest possible complication rate and satisfac- beyond its conventional indications as an alternative to
tory aesthetic outcomes to obtain equivalent survival mastectomy to embrace patients with larger, multifocal/
when compared to mastectomy while protecting natural multicentric tumors, patients who are otherwise candi-
shape, form and function of the breast. To achieve these dates for mastectomy due to tumor/breast volume ratios
goals, the issue that should be emphasized, is the impor- and extensive microcalcifications [31–35].
tance of detailed patient evaluation to select the optimal
surgical procedure. It is a matter of fact that after conven-
tional breast conservation (CBCS) with radiation thera- Evolving Indications and Contraindications/
py, a great number of patients suffer unacceptable sequels Evolution of OBCS
[13, 24]. In most cases, correction or reconstruction of
these deformities is possible, but remains complex with Unquestionably, oncologic principles of breast con-
unpredictable outcomes requiring various operations servation should remain uncompromised in every surgi-
and occasionally creates major stress and anxiety for the cal approach attempting to treat BC. Nevertheless, today
patients and sometimes leads the path to mastectomy we are well aware that every breast conservation should
[25]. The employment of oncoplastic techniques at the be designed within the perspective of oncoplastic princi-
initial procedure prior to radiotherapy is a valid attempt ples and should involve oncoplasty. The established indi-

Innovative Standards in Oncoplastic Breast Care 2021;16:559–573 561

Breast Conserving Surgery DOI: 10.1159/000518992
cations should be approved during multidisciplinary tu- mammoplasty techniques for partial breast reconstruc-
mor board meetings with respect to tumor and patient tion and reshaping. Another system for clinical practice
characteristics, including genetics, if available. Patient is the Basel classification providing four categories of
factors including comorbidities, not only the chronologic conventional and oncoplastic breast conservation re-
but the biologic age with frailty indices and predicted life garding tumor excision, mastopexy, or reduction mam-
span of each patient should be taken into consideration moplasty based on the key steps and propose algorithmic
before decision making. Oncoplastic surgery is indicated approach for indications and reconstructive decision
for every case when there is a risk of deformity, which making [38]. Recently, in 2019, the American Society of
could be accepted as more than 80 g of breast tissue re- Breast Surgeons (ASBrS) endorsed the European defini-
sected from a medium-sized breast as a rule, irrelevant to tion and published a classification similar to Clough et al.
the technique employed [17]. The conventional contrain- [21] regarding volume displacement with volume re-
dications of OBCS such as lager tumor size relative to placement techniques including both implant-based and
breast size and/or multicentricity has been largely aban- locoregional flap reconstructions in their consensus state-
doned via the dominating role of neoadjuvant treatments ment [23]. Nevertheless, it should be emphasized that
for tumor shrinkage and generations of various tech- volume-based classification systems have been proposed
niques with increased experience [36]. So far, OBCS is the to guide clinical practice offering surgeons multiple op-
procedure of choice in each case who is an appropriate tions based on the percentage of breast gland to be re-
candidate for BCS with similar contraindications such as moved or reconstructed and serve to make decision pro-
inflammatory BC or history of irradiation. As breast sur- cess simple and safe relevant to breast and tumor charac-
geons, our mission is not only to operate, but we must teristics along with patient’s expectations.
gain optimal levels of competency regarding molecular
biology, genetics, and diagnostics of BC for appropriate
decision making. Current Issues about Standardization of OBCS

Currently, the techniques that are used for the recon-

Proposed Algorithms for Standardization: struction of the defect after tumor removal are based on
Classifications two different concepts. These are volume displacement
procedures; using glandular/dermoglandular transposi-
Various algorithms and templates have been proposed tion flaps, redistributing glandular tissue into resection
regarding the classification of OBCS to create homogene- cavity, which might require nipple elevation with reposi-
ity, diminish complexity and form a basic lexicon for pa- tioning and various types of mastopexy regarding tumor
tients, surgeons, trainees, and educators for standardiza- site and breast size. The reduction mammoplasty is the
tion worldwide [17, 23, 37–39]. Moreover, an interna- procedure of choice for larger ptotic breasts. On the other
tional consensus conference on standardization of OBCS hand, volume replacement interventions are preferred for
has been conducted in 2017 with a conclusion remark of smaller breasts employing autologous tissue transfer from
tailored OBCS approach to each case [40]. From that an extramammary area to compensate for the deficient
point on, oncoplastic surgery methods could be catego- volume after resection that could be accomplished in sev-
rized regarding complexity from simple to complicated eral ways, such as latissimus dorsi or transversus abdomi-
[40, 41]. In the Hoffman classification complying with nis flaps or implant-based reconstructions [42, 43]. These
documenting and billing purposes, the rate of breast tis- methods require different levels of competency, training,
sue mobilization was proposed to define oncoplastic pro- and experience. One of the most crucial issues about stan-
cedure which is more than 25% and rearrangement of the dardization of the proposed classification systems is the
defect area via local glandular advancement flaps, masto- lack of accreditation of training and practice worldwide.
pexy, reduction mammoplasty or distant flaps in accor- Despite the prevalent acceptance of OBCS in Europe since
dance with patient’s status [37]. Similarly, Clough et al. 1980s, awareness and practice are disappointingly variable
[17] classified oncoplastic surgical techniques based on across other countries [44]. In the European model, diverse
the breast volume to be resected and the quadrant of the OBCS techniques are performed by general surgeons who
tumor located serving to standardize OBCS to adopt in became breast surgeons after adequate training and experi-
routine clinical practice for indications, designs, and per- ence. However, in some countries, plastic surgeons are for-
formance. Their dichotomization including only volume mally allowed to use volume replacement techniques.
displacement techniques denoted up to 20% of the breast Moreover, regulations across Europe are also challenging
volume to be resected as level I and 20–50% of the volume with a highly variable and generally poorly regulated train-
to be resected as level II techniques that necessitate spe- ing in breast surgery except in a few superior examples
cific training on nononcologic skin excisions and various [45]. There is an interesting debate between Europe and

562 Breast Care 2021;16:559–573 Karadeniz Cakmak

DOI: 10.1159/000518992
USA about this issue. Breast surgery is a subspecialism with be evaluated as well. As mentioned previously, oncoplastic
available fellowships in USA, but not a recognized subspe- procedures are categorized as volume displacement tech-
cialty in Europe at present. Although there is a long-lasting niques to reconstruct partial small- to moderate-size
and well-established training on breast surgery in USA, the breast defect using mammoplasty techniques including
merge of oncoplasty has only gained acceptance very re- local glandular tissue advancement flaps, mastopexy, and
cently and most of the reconstruction procedures are per- reduction mammoplasty or volume replacement proce-
formed by the plastic surgeons in the team. On the con- dures including implant based or autologous flap oriented
trary, there is no formal acceptance of breast surgeon defi- to reform a new breast after total resection [48, 49]. From
nition and training all around Europe, but the this point of view, OBCS methods could be defined re-
reconstructive part of the procedures is employed by sur- garding levels of complexity of performance from volume
geons trained and experienced in oncoplastic surgery. To displacements such as large local resections, through ther-
overcome abovementioned difficulties, European Breast apeutic reduction/mastopexy and volume replacement
Surgery Initiative, BRESO, initiated a pan-European cur- options with immediate or delayed contralateral symme-
riculum for completely trained breast surgeons aiming to trization procedures [40, 49]. The complexity of the surgi-
adopt the standards extensively and assure the quality of cal steps varies widely with respect to the degree of ptosis,
care served to each case which would address the issues breast volume, tumor volume compared to total breast
regarding standardization in OBCS in the future [46]. Up volume, and tumor location [25]. The choice of technique
to then, for the purposes of education and training each should be based on combination of several other patient-
country might employ the most suitable classification in related risk factors, such as smoking history, obesity, dia-
accordance with national regulations, resources, and inter- betes mellitus, and previous surgeries [17]. Moreover,
national recommendations, firstly focusing on basic vol- clinical stage at presentation, pathologic and genetic data,
ume displacement techniques that could be integrated into and anticipated adjuvant therapy requirements associated
the existing curriculum of practice of dedicated general with patients’ expectations should be strictly considered
surgeons to breast surgery after a training period in an ac- [24]. A great attention should be paid to scars from prior
credited breast center. breast surgery or radiation history, bra size (current, de-
sired, and possible), required skin resection and skin qual-
ity, as well as back pain due to macromastia, history of
Oncoplastic BCS: Technical Point of View lactation, and plans for future pregnancy. All these vari-
ables possess some degree of importance guiding onco-
Without a global consensus about the classification, it plastic surgeon to predict the optimal extent of tissue rear-
is a practical and pragmatic approach to categorize OBCS rangement to design a tailored surgical algorithm for each
according to the complexity of the procedures and the case in an individualized manner, not a “one size fits all”
mandatory training to be achieved before performance. fashion. The tumor location is one of the most crucial fac-
Undoubtfully, OBCS is the incredible union of science tors for deformity. Upper outer quadrant tumors gener-
and art. These two aspects are interdependent and domi- ally end up with favorable outcomes; however, upper in-
nating over the other in the course of cancer management. ner and lower pole tumors have higher risk of deformity
It would be very simplistic and crude to state that this type due to having less adjacent glandular tissue to cover cav-
of surgical de-escalation serves only to improve cosmetic ity resulting in the loss of convexity of the medial cleavage
outcome and far away from its scientific realm which also of the breast in upper inner pole tumors and downward
integrates the mission of oncologic efficiency and cost ef- positioning of NAC forming birds-beak deformity in the
fectiveness by means of providing margin negativity, de- lower pole tumors [17]. Another key issue is the mainte-
creasing the requirement of reexcisions and associated nance of the optimal relationship of the NAC to breast
risk of mastectomy, and avoiding a delay in adjuvant treat- mound after OBCS. The contraction after radiation ther-
ment [47]. The initial decision-making step is to deter- apy associated with surgical wound healing process dislo-
mine the type of oncologic surgery required, conservative cates NAC towards the defect site. These effects can be
versus mastectomy, mainly based on patient and tumor alleviated strategically by advancing glandular flaps to
characteristics. The major factors associated with breast cavity and by relocating the NAC in the central position
disfigurement and deformity are tumor site and size, of the skin envelope to be created after OBCS [50]. It mer-
breast volume, tumor to breast size ratio, percentage of its consideration that the preferred skin incision should
breast tissue to be excised, adjunct radiotherapy, and sur- also be individualized with respect to skin quality, degree
gical resection approach. Moreover, the presence and de- of ptosis, and scars from previous surgeries. Additionally,
gree of ptosis (excessive skin to be removed), glandular a symmetrization procedure to the contralateral breast
density of the breast, the desired new location of NAC could be discussed with the patient in an immediate or
after operation and contralateral symmetrization should delayed fashion. The level-based classification schemes

Innovative Standards in Oncoplastic Breast Care 2021;16:559–573 563

Breast Conserving Surgery DOI: 10.1159/000518992
mainly depend on the volume to be excised and the com-
plexity of the technique to be performed. Level I volume
displacement procedures serve to reconstruct the defects
that result from less than 20% of the breast volume with-
out the need of skin sacrifice and mammoplasty in women
with small- to moderate-sized breasts with dense glandu-
lar characteristics [17]. The resultant cavity after partial
mastectomy is filled with rearrangement of local glandular
advancement flaps via dual plan undermining of the pa-
renchymal tissues forming cavity walls from the skin and
underlying pectoralis fascia and terminated with reap-
proximating the edges without leaving death space [51].
In low-density breasts, mainly composed of fatty tissue
(BIRADS A-B), the dual plan undermining could lead to
higher risk of fat necrosis. Accordingly, it is of paramount
importance to evaluate glandular density in mammogra-
phy before decision making to limit the amount of dual
plan undermining in level I OBCS or to proceed directly
to level II techniques which is suitable with only posterior
detachment and the skin left intact. The distortion or mal-
position of the NAC should be avoided. The criteria for
level II oncoplastic procedures were defined as maximum
excision volume ratio between 20 and 50% in women with
dense or fatty glandular characteristics of medium to
large, heavy, ptotic, or macromastic breasts requiring skin
excision and mammoplasty for reshaping [17, 42]. The
location of the skin incisions will affect the displacement
of NAC leading to asymmetry between contralateral
breasts. Oncoplastic reduction mammoplasty is one of the
most common OBCS procedure in routine clinical prac-
tice and is the procedure of choice for larger tumors and
large breasts [15]. Several skin incisions have been defined
Fig. 1. OBCS techniques: keep it simple and safe.
subjecting to the primary tumor location, the amount of
required skin resection, and the designed new position of
the NAC after resection. These include Wise pattern re-
duction for larger breast requiring extensive skin resec- plasty for tumors that are close to the inframammary fold
tions or more conservative methods such as vertical scar located in the lower inner quadrant, batwing mammo-
mammoplasties. The pedicle to NAC can be created from plasty for upper inner quadrant tumors, and J-scar mam-
any direction with respect to the tumor location. In a pa- moplasty for lower outer quadrant tumors shown in Ta-
tient with grade II or more ptosis who presented with low- ble 1 [17, 52, 53]. In patients with small- to moderate-sized
er or upper pole tumors, the surgical algorithm could be breast for whom more than 50% of the breast volume is to
provided via a Wise pattern or vertical scar reduction with be excised, or skin replacement is required, volume re-
modification of the NAC pedicle to be based opposite re- placement methods should be the option of choice with
garding the site of tumor resection. For upper pole tumors great consideration for which previous surgery to lateral
an inferiorly based pedicle and for lower pole tumors su- chest wall, such as posterolateral thoracotomy, made it
periorly based pedicles could be preferred. Another pre- impossible to employ an autologous flap of latissimus dor-
ferred technique for patients with a small- to medium- si demonstrated in Figure 1 [23, 48, 54].
sized breast that has adverse peripheral tumor locations,
except close location to inframammary fold, is round
block (Benelli-Donut) mastopexy. There are other various Multidisciplinary Team Approach for OBCS
well-established OBCS techniques, including Grisotti
flaps for centrally located tumors for which NAC preser- The optimal management in BC should be formulated
vation is out of question, the racquet (hemibatwing) mam- by a dedicated multidisciplinary breast team. Multidisci-
moplasty for lateral outer quadrant tumors, V-mammo- plinary board meetings are proposed to be the standard

564 Breast Care 2021;16:559–573 Karadeniz Cakmak

DOI: 10.1159/000518992
Table 1. Tumor location and breast size-based OBCS techniques

Tumor location Oncoplastic mastopexy Reduction mammoplasty

Smaller breast (A, B cup) Large breast (C, D cup)
Small tumor Large volume exc.
Up to moderate ptosis (Grade 1–2) Severe ptosis (Grade 3–4)

Upper pole (12 o’clock) Round block Inferior pedicle Wise pattern
Crescent mastopexy
Upper inner quadrant Round block Inferior pedicle Wise pattern
Batwing mammoplasty
Crescent mastopexy
Upper outer quadrant Lateral (Racquet) mammoplasty/radial scar Inferior/superomedial pedicle Wise pattern
Round block
Crescent mastopexy
Lower outer quadrant Round block Superomedial/inferior pedicle Wise pattern
J scar mammoplasty
Lower quadrant junction Vertical mammoplasty Superomedial pedicle
(5–7 o’clock) Round block Inverted T-Wise pattern
Lower inner quadrant V mammoplasty Inferior/superomedial pedicle
Superior pedicle mammoplasty Inverted T-Wise pattern
Doughnut mastopexy (small tm, up to moderate ptosis)
Central subareolar Grisotti flap reconstruction Inverted T or vertical scar mammoplasty with
NAC resection

of care to improve quality standards in health care ser- crucial support to accurately design the comprehensive
vices and obliged by regulations in some countries [55, therapy algorithm for an individual case which has an im-
56]. Each discipline plays a critical role representing his/ pact on prognosis. Multidisciplinary team meetings are
her significant expertise to make evidence-based recom- the place to discuss and decide on the most convenient
mendations regarding the optimal individualized care for treatment design to be recommended. The cooperation
cancer patients [57]. In the multidisciplinary approach, with collaboration is the cornerstone to achieve the estab-
the realm of the breast surgeon remains to be the ana- lished goals in OBCS.
tomic, morphologic, and technical decisions regarding
surgery along with patient’s choices. Nevertheless, the
major role is to share the proposed surgical treatment Is Oncoplastic Surgery Safe? Oncologic Outcomes
with the board to ensure not to compromise other adju-
vant treatments modalities which are necessary. The con- The mounting volume of data now available support-
troversy about the best team approach persists with ex- ing that oncologic outcomes of OBCS are superior or at
ceptions in areas of well-defined surgical training on least comparable to conventional BCS, albeit the majority
OBCS, globally. Generally, with the fact that plastic sur- of the studies are observational without balanced arms,
geons are the pioneers of flap-based breast reconstruc- lacking strict patient selection criteria, without standard-
tion, their presence in the team is invaluable. However, ized oncoplastic techniques, with existing controversy re-
regarding the geographic area of the service provided, garding margin status and having relatively favorable tu-
plastic surgeons may be unavailable or not demanding to mor characteristics, the importance of the research efforts
get involved in BC management, which is the rationale to be focused on level I evidence, should be emphasized.
beyond the fact that breast surgeons trained and skilled in From this point of view, oncologic safety could only be
OBCS techniques are of paramount importance and evaluated by comparing time-to-event endpoints such as
mandatory to provide the quality of care that each patient OS, DFS, local recurrence-free survival (LRFS), locore-
deserves [58–61]. The question is not the performer, but gional recurrence (LRR), or distant recurrence which is
the fashion of the art that is performed which creates the possible via randomized clinical trials that currently do
state of the art. The professionalism is to optimize the care not exist . In a retrospective analysis of 1,177 patients un-
but not to compromise it due to primitive interdisciplin- dergoing OBCS, 75% of whom had a T1 or T2 tumor, the
ary discussions. Each BC specialist in the team provides 3-year OS and LRFS rate were 95.8% and 94.6%, respec-

Innovative Standards in Oncoplastic Breast Care 2021;16:559–573 565

Breast Conserving Surgery DOI: 10.1159/000518992
tively, which was similar to CBCS [62]. From the data The innovative standards in surgery of the breast after
from European Institute of Oncology with a longer peri- neoadjuvant therapy is a hot topic of enthusiasm and will
od of follow-up, 7.2 years, 454 patients reported a 5-year be addressed in detail in another article in this issue. Nev-
OS rate of 95.9% which is higher than CBCS. However, a ertheless, two studies about oncologic outcomes follow-
slight increase in LRR was observed in the OBCS group ing neoadjuvant treatment for patients undergoing OBCS
without statistical significance (3.2 vs. 1.8% at 5 years, and merit consideration. The first one is from the Institut
6.7 vs. 4.2% at 10 years) and long-term effect on OS (95.9 Gustave Roussy including 259 patients who underwent
vs. 95.4% at 5 years, and 91.4 vs. 91.3% at 10 years) [63]. BCS after neoadjuvant systemic therapy, demonstrating
More recently, a retrospective cohort study analyzing similar rates of recurrence within a 46-month follow-up
1,800 patients followed-up over 75 months (median) re- period in patients with or without oncoplastic methods (4
vealed no difference regarding LRFS between conven- vs. 5%, respectively; p = 0.90) [72]. Another study from
tional and 611 OBCS patients, even though the OBCS Emory University Hospital, including 87 high-stage (>T2
group was younger and suffering from more aggressive or at least N1) OBCS patients, revealed a local recurrence
tumors than the conventional group [64]. Similarly, rate of 6% for a median period of 44 months [73].
Oberhauser et al. [65] analyzing the data of 283 patients, Although there is mounting literature about OBCS,
188 of whom underwent OBCS, reported no significant most of it is of retrospective nature, with limited number
differences in the positive margin rate and in the LR rate of cases and heterogenous, forming a controversy due to
after OBCS versus conventional counterpart. Recently, absence of accurate definition regarding margin status,
Clough et al. [66] reported 10-year follow-up (median: 55 distribution of tumor stage, or the oncoplastic technique
months) data of 350 oncoplastic breast reductions per- utilized. Accordingly, there is no level 1 evidence to ac-
formed in L’Institut du Sein between 2004 and 2016, and curately confirm the safety of OBCS emphasizing the im-
the cumulative 5-year incidences for local, regional, and portance of the need of standardization of oncoplastic
distant recurrences were 2.2, 1.1, and 12.4%, respectively. techniques and initiation of multinational registry sub-
A systematic review by Piper et al. [67] evaluating the on- missions of patients treated with OBCS.
cologic outcomes of oncoplastic mammoplasty in 1,324
cases reported a pooled LRR rate of 3.1% with at least 2
years’ follow-up. Another systematic review including Aesthetic Outcome Assessment
more than 6,000 patients with a mean follow-up 50.5
months revealed local and distant recurrence rates of 3.2 An ideal method and time of aesthetic assessment after
and 8.7% for T1-T2 BC following OBCS [68]. The meta- OBCS has yet to be devised, since there are significant
analysis by Losken et al. [69] of 3,165 patients treated with discrepancies in the literature [74]. Theoretically, the
oncoplastic techniques (1,773 reductions and 1,392 flap method of choice should be dependent on simple quan-
reconstructions) compared to 5,494 CBCS found reexci- titative measures necessitating minor expertise, easy to
sion was more common (14.6 vs. 4%, p < 0.0001), and lo- reproduce, well correlated with the patient’s self-reported
cal recurrence was higher (4 vs. 7%, p < 0.0001) in the cosmetic outcome, documented via permanent records of
conventional group with no difference between the onco- patient views allowing comparison in the future when re-
plastic techniques utilized. The latest meta-analysis of quired. There are subjective and objective evaluation
18,103 patients with a primary outcome measure of re- tools for aesthetic outcome assessment that can be per-
currence using pool analysis technique found nothing formed real time on patient or via photos, prints, digital
significant between OBCS, CBCS, or mastectomy (RR images. Subjective methods involve patient self-assess-
0.861; 95% CI 0.640–1.160; p = 0.296), confirming the hy- ment or evaluation by a single/panel of observers. Objec-
pothesis that extensive excision did not translate into su- tive tools consist of multiple different types of quantifica-
perior oncologic outcomes [70]. The determined signifi- tions and software. The documentation and recording of
cance favoring OBCS in the secondary outcome measure the patients’ images are vital for comparison since the
of reoperation disappeared after analysis for publication process determining cosmetic outcome is dynamic and
bias (RR 0.86; 95% CI 0.56–1.31; p = 0.44) [70]. In con- tends to alter over time due to specific influence of sur-
trast, the meta-analysis by Yiannakopoulou and Mathelin gery and radiation therapy. Timing for imaging should be
[71] concluded that extensive variation in the frequency standardized, and images should be acquired before any
of margin involvement (ranging between 0 and 36%), lo- treatment (baseline photograph), before radiotherapy, 1
cal recurrence (0–10.8%), and distant metastasis (0– year after radiotherapy, and ideally be repeated at 5- and
18.9%) persists in the literature, which points out the fact 10-year follow-ups [75]. The rationale is to turn subjec-
that long-term oncologic outcome of OBCS is not ade- tive to objective; accordingly, various objective assess-
quately investigated. ment methods have been proposed including breast re-
traction assessment and software such as breast symme-

566 Breast Care 2021;16:559–573 Karadeniz Cakmak

DOI: 10.1159/000518992
try index (BSI) and the BC Conservative Treatment quality indicators. Currently, there is no accepted defini-
Aesthetic Results (BCCT.core) tool with the limitation of tion of value in OBCS, in terms of general outcome as-
inability to make evaluation in 3 dimensions [76–78]. sessment. The tools in routine clinical practice are far
Then, 3D cameras have been employed in conjunction from being homogeneous and may not reflect outcome
with software that has not yet been validated in routine accurately in each case. The integration of objective aes-
practice due to high cost and limited access [79]. Address- thetic outcome assessment with PROs is a complicated
ing the optimal assessment tool for cosmetic outcome, process. There are various PRO metrics for BC surgery;
open questions in the published literature are: who should one of the most widely used tools is BREAST-Q which is
perform aesthetic evaluation and methods to be used/by validated, specific, translated into many languages and
means of which method. For subjective assessment, pa- involves QOL domains evaluating physical, psychosocial,
tient’s self-evaluation is fundamental, since after OBCS and sexual well-being, and satisfaction domains assessing
and radiotherapy, it is not the physician’s or panel’s deci- satisfaction with breasts, outcome, and care [87, 88]. Oth-
sions that count – patient’s feelings are the cornerstone of er available options are the European Organisation for
QOL. Of note, patients consistently report scores supe- Research and Treatment of Cancer (EORTC) QLQ-C30,
rior than professionals [80]. Despite the extensive varia- and the EORTC QLQ-BR23 questionnaires [89–91]. In a
tion among the articles published concerning optimal literature review by Char et al. [92], BREAST-Q data
time and methods, the data about cosmesis after OBCS showed OBCS had significantly higher scores than mas-
seem encouraging. When compared to CBCS, with ac- tectomy regardless of the type of the reconstruction per-
ceptable results in 60–80% of cases, good cosmetic out- formed. In another systematic review performed by Aris-
comes after OBCS were reported up to 90% [29, 81]. Pa- tokleous and Saddiq [93] evaluating patients’ QOL, OBCS
tient-reported superior cosmetic outcomes have a mirror was found to be associated with a trend toward better pa-
effect that is directly proportional to patient’s body image tient QOL than BCS alone. In a study including 120 pa-
and QOL [80]. As a matter of fact, superior aesthetic out- tients who had OBCS, a median score for the domain for
comes which fulfill patient expectations are one of the satisfaction with breasts on BREAST-Q was 74, and 91%
major factors favoring performing oncoplastic tech- of them claimed that their expectations were almost en-
niques in each case eligible for breast conservation [74, tirely met by the operation regarding the cosmetic out-
81, 82]. In 2017, the panel of the first international con- come [94]. Therapeutic mammoplasty patients were
sensus conference on standardization of oncoplastic sur- deemed to be significantly more satisfied than those un-
gery reached consensus to recommend photographic dergoing autologous tissue reconstruction options (latis-
documentation of all patients before and after surgery as simus dorsi mini flap) with the shape, the size, and the
standard for clinical routine practice [40]. However, natural feel of the treated breast [95]. The other issue is
mentioning the importance of semiautomatic software the body image following BC surgery. The comparison of
for objective assessment, the panel did not recommend OBCS with mastectomy and immediate breast recon-
the standard use due to the limited correlation between struction significantly favored OBCS regarding overall
objective and PROs with feasibility issues. Currently, the body image score, patient rated breast appearance and
nature of the qualitative subjective evaluations without return to work and function [96]. The generation of ro-
quantitative measures leading to biased outcome analysis bust but ununiform data about OBSC due to the absence
is a fact for OBCS. Accordingly, internationally accepted, of standardized practice creates a matter of controversy
uniform, homogenous, and reproducible validated tools regarding the outcomes reported. It merits consideration
with objective scoring systems coinciding with patient to emphasize that the data gathered from an ongoing pro-
perspective to assess cosmetic outcome do not exist and spective clinical trial from Netherlands, entitled The
are strongly required for standardization [74, 80, 83]. COSMAM, which is a cohort study assessing patient-re-
ported and cosmetic outcomes in patients with BCS
alone, versus a level I or level II OBCS, would be capable
QOL Outcomes Assessment of giving right and unbiased answers for these controver-
sial issues [97]. The future of quality improvement and
Quality of cancer care is multifaceted and consolidates standardization is only possible via conceptualizing value
traditional outcomes such as survival, efficacy, and safety, via quality indicators in OBCS for which PROs regarding
but fundamental measures of value to be recognized are QOL are the fundamental variable. Until then, these
PROs reflecting the patient preferences and goals includ- questionnaires are recommended as convenient tools to
ing QOL, satisfaction, and shared decision making [84– evaluate primary outcomes, but other metrics for PROs
86]. The scope of evidence-based cancer care should be should be systematically measured and quality indicators
expanded to value-based and patient centered algorithms of surgical morbidity and adverse events should be iden-
via systematic integration of PROs metrics to quantify tified and validated in further prospective trials [86].

Innovative Standards in Oncoplastic Breast Care 2021;16:559–573 567

Breast Conserving Surgery DOI: 10.1159/000518992
 Standardization of Outcome Assessment plastic reduction mammoplasty included 4.6% wound
dehiscence, 4.3% fat necrosis, 2.8% infection, 0.9% nipple
Our goal today is not only to achieve a longer, but a bet- necrosis, and 0.6% seromas [67]. In a single-institution
ter life regarding outcomes for BC patients. Unfortunately, series including nearly 10,000 patients, when compared
the major issue about outcome assessment following OPBS to CBCS, OBCS was reported to lead to lower rates of se-
and radiation therapy is the absence of standardized quan- roma (13.4 vs. 18%; p = 0.002) but a higher incidence of
titative evaluation measures to permit comparative re- wound-associated complications (4.8 vs. 1.4%; p =
search and to access high level of evidence which is a must 0.0001), with a comparable rate of infection (4.5 vs. 4.1%;
to create applicable guidelines. Most of the trials in the lit- p = 0.61) [62]. In a recent study by Oberhauser et al. [65],
erature are retrospective in nature, heterogeneous with re- without significant difference in short-term complica-
gard to the techniques utilized for OPBS and limited due to tions, the rate of long-term morbidity, regarding chronic
the study design. The quality metrics of current evidence on pain and lymphedema, was reported to be 25.5% which is
OBCS is far from desired, not only due to lacking random- significantly higher compared to CBCS (11.3%) (100 pa-
ized controlled trials, but the vast majority is composed of tient-years, p < 0.001) that did not cause any delay to ad-
inconsistent and underpowered studies with the possibility juvant treatment. In accordance, recently reported out-
of concealed data [98]. The knowledge gap in this area re- comes of Clough and colleagues for level II mammaplas-
quires prospective cohort studies at an international level as ties revealed a rate of 12.5% for margin positivity, 8.9%
a research priority [85]. The visible impact of surgery and for postoperative complications and 4.6% for delay for
adjunct radiation therapy on body image is a dynamic pro- adjunct therapies [66]. In larger series with a volume dis-
cess differing individually and changing with time. The placement approach, variable rates of complications up
quest to find the gold standard tool for evaluation has to 15% for wound healing issues, 3–10% for fat necrosis,
evolved tremendously in the last 4 decades initiating from and 1–5% for infection have also been demonstrated
manual, subjective approaches to software-based and auto- [101, 102]. Overall complication rates regarding volume
mated solutions. However, none of these succeeded to ma- replacement techniques are slightly higher ranging from
ture enough to become standard. Currently, recent ad- 2 to 77%, which might be attributed to the extra effect of
vancements in the paradigm of artificial intelligence and donor site and flap viability problems [103, 104].
deep learning have an inspirative effect toward AI-based
image analysis which would lead to promising objective
analysis of outcomes within standardized manner and Impact of OBCS on Oncologic Treatment Initiation
higher accuracy after OBCS in the future [99]. Until then,
current methods such as PROs, subjective and objective With great advance and effort to optimize outcomes
evaluation tools defined as state-of-the-art methods should after breast conservation, margin positivity remains a
be conducted for documentary purposes. problem which leads to reoperations after lumpectomy
and to delays in adjuvant treatment. In a recent analysis
of National Cancer Database (NCDB) dataset by Lander-
Complications of OBCS casper et al. [105] including more than 520,000 women,
the overall reoperation rate was reported to be 16.1% after
With the well-defined benefits of OBCS such as de- BCS with a significant interfacility variation, which is
creased requirements for secondary interventions for much higher than the recommended European quality
margin positivity, reduced mastectomy rates due to larg- benchmark of less than 10% [106]. When compared to
er volumes of resection, and lower risk of complications CBCS, OBCS has consistently been proven to increase the
compared to traditional surgery, the complication rates rates of negative margins (88–94%), decrease the need for
of OBCS in the literature have been relatively variable in reoperations, mastectomy, and local recurrence, while
terms of the level of the procedure performed [100]. One improving the cosmetic outcome for larger excisions [68,
of the most important issues is the risk of delay of adju- 69, 100]. A systematic review by De La Cruz et al. [68]
vant treatment due to any surgery-related complication evaluating more than 5,000 patients who underwent
which would lead to undesirable consequences on prog- OBCS in 49 studies declared an average positive margin
nosis. While randomized controlled trials do not exist, rate of 10.8%, reexcision rate of 6.0%, and conversion to
retrospective cohort analyses comparing CBCS with mastectomy rate of 6.2% which is lower than CBCS. In
OBCS have generally revealed acceptable morbidity pro- accordance, in another meta-analysis Losken et al. [69]
files [68, 69]. Overall complication rates after OBCS range found a statistically significant lower rate of margin posi-
from 8.9 to 24.6% depending upon definitions, which is tivity (12%) for OBCS relative to CBCS (21%) in an eval-
comparable with previous values associated with BCS uation of 8,659 patients after oncoplasty. From this point
alone [69]. The pooled rates of complications after onco- of view, educating individual breast surgeons to be com-

568 Breast Care 2021;16:559–573 Karadeniz Cakmak

DOI: 10.1159/000518992
petent in OBCS would allow larger resections and margin tion mammoplasties when compared to BCS alone (21.2
clearance at the index procedure sparing reexcisions and months) with a slightly longer trend to mammographic
timely initiation of adjuvant treatments. stability in the OBCS (25.6 months) group. Similarly, Pip-
er et al. [114] demonstrated no difference between OBCS
and lumpectomy alone regarding postoperative mammo-
OBCS and Radiation Therapy Design graphic abnormalities and unnecessary biopsies up to 5
years. In contrast, over an average of 7 years, a higher rate
The essential role of adjuvant radiation after breast of tissue sampling of 53% has been documented in the
conservation for local control is more complex following OBCS group when compared to 18% in the BCS group
OBCS [107–109]. There are two major issues to be empha- [115]. In another comparative study, significantly more
sized. One of them is the impact of oncoplasty on the prac- patients undergoing OBCS required breast ultrasound
tical application of radiation to tumor cavity which re- (28 vs. 15%; p = 0.024) and consequent biopsies (12.6 vs.
mains unclear. The second is the time to initiation of ir- 2.5%; p = 0.006) when compared to the BCS group, most
radiation. Accurate targeting of the tumor bed is essential of which were due to fat necrosis [116]. Accordingly, a
for both the partial breast irradiation and tumor bed boost. strong collaboration between the patient, surgeon, and
Relevant to the degree of glandular tissue advancement or radiologist is a must to optimize but not compromise the
reduction, the accurate determination of tumor bed re- outcomes beginning from the surgical decision process
quires more than incisional boundary to plan radiation until surveillance. The patients should know they will ex-
treatment via the images of axial computed tomography. perience additional biopsies in the follow-up period after
In patients for whom boost dose to tumor bed is required, OBCS, and the breast surgeon should accurately inform
a comprehensive dialog between breast surgeon and the the radiologist about the operative techniques employed
radiation oncologist on a case-by-case basis is vital to and the new form of the tissue planes in the reconstructed
guarantee the appropriate radiation therapy. Of note, rou- breast via which imaging differences would be interro-
tine clip placement during surgery guides radiation on- gated accurately in the postoperative dynamic period of
cologist to designate the most absolute area for radiother- the wound healing process within long years of follow-up.
apy. A survey revealed that for mastopexy patients, 38.7%
of radiation oncologists preferred to deliver a boost dose
only when clips have been settled in cavity at the surgery What Is on the Horizons?
[110]. The time period from surgery to initiation of irra-
diation is directly proportional to LR, and when the inter- Surgical management of BC continues to evolve, and
val is beyond 8 weeks it has detrimental consequences innovations in OBCS, in particular the paradigm shift to-
[107, 111, 112]. In a study by Tenofsky et al. [29], a higher wards extreme oncoplastic techniques (EOPT) began to
rate of wound healing complications after OBCS was re- question traditional indications for mastectomy. “Ex-
ported not to prolong time to radiation in OBCS patients. treme oncoplasty” was first described by Silverstein et al.
On the other hand, in a more recent study, postoperative [35] as “breast conserving operation, using oncoplastic
complications after OBCS were reported to result in a sig- techniques, in a patient who, in most physicians’ opin-
nificantly longer median time period for initiation of ra- ions, requires a mastectomy’’ [35]. EOPT broaden the
diotherapy with 74 days, when compared to 54 days with- limits regarding breast conservation via serving oncolog-
out a complication (p < 0.001) [47]. In this regard, all these ic safety for cases with tumors larger than 5 cm and/or
possibilities should be discussed frankly with the patient multicentric or multifocal tumors [31–35]. Following
to warrant a multidisciplinary approach preoperatively in large excisions, EOPT employing lateral, medial or ante-
accordance with patient desires about the oncoplastic rior intercostal artery perforator flaps, mini lattissimus
technique to employ and radiation therapy. To conclude, dorsi flaps, or thoracodorsal artery perforator flaps re-
the integration of oncoplastic techniques has implications garding tumor location for volume replacement provide
for radiation therapy planning and outcomes. Neverthe- versatile outcome with acceptable scars on donor site [49,
less, prospective, multidisciplinary collaborative trials 103, 104]. However, it should be emphasized that solely
evaluating the long-term consequences are thus called for. surgical manual dexterity is neither enough nor appropri-
ate to optimize the oncologic and aesthetic outcome. Ac-
cordingly, meticulous preoperative staging to design the
Surveillance after OBCS individualized oncoplastic technique is vital. Innovation
is a function of technology. The technical improvement
Surveillance following OBCS is another topic of inter- providing margin negativity, which is a must for OBCS,
est with various ambiguities. Losken et al. [113] reported merits consideration. Intraoperative ultrasound guid-
similar quantitative mammographic findings after reduc- ance is one of the most enthusiastic issues for margin

Innovative Standards in Oncoplastic Breast Care 2021;16:559–573 569

Breast Conserving Surgery DOI: 10.1159/000518992
clearance at the initial surgical procedure particularly in Conclusion
the era of neoadjuvant systemic therapy [117, 118]. Ad-
ditionally, novel technologies such as indocyanine green- As a matter of fact, the major issue concerning surgical
guided surgery and near-infrared fluorescence imaging management of BC currently seems to be overtreatment.
are being proposed as major role players for margin as- Precision medicine has become an important concept of
sessment [119]. cancer care to customize health care and make decisions
Moreover, we have updated the bigger is not better is- based on individual cases. In the past, the philosophy of
sue with enough is enough, and currently the discussion cancer management was just “one size fits all” without
focusses on less is more philosophy either in breast or ax- very specific therapies. As the data providing evidence
illary management. However, the evolution of surgical about the mastering effect of tumor biology on BC prog-
care from Halstedian radical mastectomy to extreme nosis, more targeted therapies are in practice. Today per-
OBCS is unlikely to be the final player on stage. The in- sonalized diagnostics and surgical care are the mainstay
novations in this era will continue to improve the spec- of cancer management serving to optimally treat each in-
trum of patients eligible for oncoplasty, particularly with dividual on a case-by-case basis. The rule is not to do too
the dominating role of neoadjuvant therapy. Further- much in order not to cause damage due to excessive treat-
more, recent studies emphasizing higher OS and DSS af- ment, not to do too little which will not be enough to treat
ter breast conservation than mastectomy merit consider- the cancer, but to do what is optimal to treat each patient
ation [120–122]. The molecular pathways or subgroups with the least side effect and maximum benefit. Although
for whom conservative approaches are superior to mas- there are well-established and solid knowledge gaps re-
tectomy are a matter of future trials. Moreover, we are garding standardization of education, technique selec-
facing an age in which omitting surgery for complete re- tion and outcome assessment, today, OBCS is the stan-
sponders after neoadjuvant therapy is a topic of great en- dard of care for every patient eligible for breast conserva-
thusiasm and controversy [123]. The options are limit- tion. As the multidisciplinary cancer management is
less, there would be a room for BC management without dynamically evolving, breast surgeons should be the pio-
surgery with the long-term outcome data of ongoing clin- neers to lead, research, and innovate standards for OBCS,
ical trials investigating this issue. Until then, the surgical which are the major factors to improve the quality of care
perspective about BC should focus on integrating onco- each BC patient deserves irrelevant of the geography.
plastic techniques to each conservative intervention and
training competent breast surgeons mastering oncoplas-
tic and reconstructive techniques. History repeats itself, Conflict of Interest Statement
today individualized BCS via oncoplasty remains the gold
standard therapy for eligible patients. However, the stan- The author had no conflicts of interest to declare.
dard of care in the future would be the approaches which
are considered to be unacceptable today, just like the sta-
Funding Sources
tus of breast conservation in the previous ages of radical
procedures. The major paradigm shift that has been es- No funding was received in the course of preparation and as-
tablished and suited accurately to the armamentarium of sembly of this article.
BC surgery is the Veronesi’s philosophy emphasizing not
the maximally tolerated, but the minimally effective ther-
apy.

References
1 Halsted WS. I. The Results of Operations for 3 Fisher B, Bauer M, Margolese R, Poisson R, 5 Fisher B, Anderson S, Bryant J, Margolese RG,
the Cure of Cancer of the Breast Performed at Pilch Y, Redmond C, et al. Five-year results of Deutsch M, Fisher ER, et al. Twenty-year fol-
the Johns Hopkins Hospital from June, 1889, a randomized clinical trial comparing total low-up of a randomized trial comparing total
to January, 1894. Ann Surg. 1894 Nov; 20(5): mastectomy and segmental mastectomy with mastectomy, lumpectomy, and lumpectomy
497–555. or without radiation in the treatment of breast plus irradiation for the treatment of invasive
2 Fisher B, Montague E, Redmond C, Barton B, cancer. N Engl J Med. 1985 Mar;312(11):665– breast cancer. N Engl J Med. 2002 Oct 17;
Borland D, Fisher ER, et al. Comparison of 73. 347(16):1233–41.
radical mastectomy with alternative treat- 4 Fisher B, Jeong JH, Anderson S, Bryant J, 6 Veronesi U, Cascinelli N, Mariani L, Greco
ments for primary breast cancer. A first report Fisher ER, Wolmark N. Twenty-five-year fol- M, Saccozzi R, Luini A, et al. Twenty-year fol-
of results from a prospective randomized low-up of a randomized trial comparing radi- low-up of a randomized study comparing
clinical trial. Cancer. 1977 Jun; 39(6 Suppl l): cal mastectomy, total mastectomy, and total breast-conserving surgery with radical mas-
2827–39. mastectomy followed by irradiation. N Engl J tectomy for early breast cancer. N Engl J Med.
Med. 2002 Aug;347(8):567–75. 2002;347(16):1227.

570 Breast Care 2021;16:559–573 Karadeniz Cakmak

DOI: 10.1159/000518992
 7 Blichert-Toft M, Nielsen M, Düring M, 19 Di Micco R, O'Connell RL, Barry PA, Roche 32 Tan MP, Sitoh NY, Sim AS. Breast conserva-
Møller S, Rank F, Overgaard M, et al. Long- N, MacNeill FA, Rusby JE. Standard wide lo- tion treatment for multifocal and multicentric
term results of breast conserving surgery vs. cal excision or bilateral reduction mammo- breast cancers in women with small-volume
mastectomy for early stage invasive breast plasty in large-breasted women with small tu- breast tissue. ANZ J Surg. 2017 Jun;87(6):E5–
cancer: 20-year follow-up of the Danish ran- mours: surgical and patient-reported out- E10.
domized DBCG-82TM protocol. Acta Oncol. comes. Eur J Surg Oncol. 2017 Apr; 43(4): 33 Losken A, Hart AM, Dutton JW, Broecker JS,
2008;47(4):672–81. 636–41. Styblo TM, Carlson GW. The Expanded Use
8 Litière S, Werutsky G, Fentiman IS, Rutgers 20 Rose M, Svensson H, Handler J, Hoyer U, of Autoaugmentation Techniques in Onco-
E, Christiaens MR, Van Limbergen E, et al. Ringberg A, Manjer J. Patient-reported out- plastic Breast Surgery. Plast Reconstr Surg.
Breast conserving therapy versus mastectomy come after oncoplastic breast surgery com- 2018 Jan;141(1):10–9.
for stage I-II breast cancer: 20 year follow-up pared with conventional breast-conserving 34 Pearce BCS, Fiddes RN, Paramanathan N,
of the EORTC 10801 phase 3 randomised tri- surgery in breast cancer. Breast Cancer Res Chand N, Laws SAM, Rainsbury RM. Ex-
al. Lancet Oncol. 2012 Apr;13(4):412–9. Epub Treat. 2020 Feb;180(1):247–56. treme oncoplastic conservation is a safe new
2012 Feb 27. 21 Clough KB, Nos C, Fitoussi A. Oncoplastic alternative to mastectomy. Eur J Surg Oncol.
9 Agarwal S, Pappas L, Neumayer L, Kokeny K, conservative surgery for breast cancer. Oper 2020 Jan;46(1):71–6.
Agarwal J. Effect of breast conservation ther- Tech Plast Reconstr Surg. 1999;6(1):50–60. 35 Silverstein MJ, Savalia N, Khan S, Ryan J. Ex-
apy vs mastectomy on disease-specific surviv- 22 Hoffmann J, Wallwiener D. Classifying breast treme oncoplasty: breast conservation for pa-
al for early-stage breast cancer. JAMA Surg. cancer surgery: a novel, complexity-based tients who need mastectomy. Breast J. 2015
2014 Mar;149(3):267–74. system for oncological, oncoplastic and re- Jan-Feb;21(1):52–9.
10 Hwang ES, Lichtensztajn DY, Gomez SL, constructive procedures, and proof of prin- 36 van la Parra RFD, Clough KB, Thygesen HH,
Fowble B, Clarke CA. Survival after lumpec- ciple by analysis of 1225 operations in 1166 Levy E, Poulet B, Sarfati I, et al. Oncological
tomy and mastectomy for early stage invasive patients. BMC Cancer. 2009 Apr;9:108. Safety of Oncoplastic Level II Mammoplasties
breast cancer: the effect of age and hormone 23 Chatterjee A, Gass J, Patel K, Holmes D, Kop- After Neoadjuvant Chemotherapy for Large
receptor status. Cancer. 2013 Apr; 119(7): kash K, Peiris L, et al. A Consensus Definition Breast Cancers: A Matched-Cohort Analysis.
1402–11. Epub 2013 Jan 28. and Classification System of Oncoplastic Sur- Ann Surg Oncol. 2021 Mar 28. Epub ahead of
11 Kummerow KL, Du L, Penson DF, Shyr Y, gery Developed by the American Society of print.
Hooks MA. Nationwide trends in mastecto- Breast Surgeons. Ann Surg Oncol. 2019 Oct; 37 Hoffmann J, Wallwiener D. Classifying breast
my for early-stage breast cancer. JAMA Surg. 26(11):3436–44. cancer surgery: a novel, complexity-based
2015 Jan;150(1):9–16. 24 Habibi M, Broderick KP, Sebai ME, Jacobs system for oncological, oncoplastic and re-
12 Davies C, Holcombe C, Skillman J, Whisker LK. Oncoplastic Breast Reconstruction: constructive procedures, and proof of prin-
L, Hollingworth W, Conefrey C, et al. Proto- Should All Patients be Considered?. Surg On- ciple by analysis of 1225 operations in 1166
col for a mixed-method study to inform the col Clin N Am. 2018 Jan;27(1):167–80. patients. BMC Cancer. 2009 Apr 8;9:108.
feasibility of undertaking a large-scale multi- 25 Honart JF, Reguesse AS, Struk S, Sarfati B, 38 Weber WP, Soysal SD, Fulco I, Barandun M,
centre study comparing the clinical and pa- Rimareix F, Alkhashnam H, et al. Indications Babst D, Kalbermatten D, et al. Standardiza-
tient-reported outcomes of oncoplastic breast and Controversies in Partial Mastectomy De- tion of oncoplastic breast conserving surgery.
conservation as an alternative to mastectomy fect Reconstruction. Clin Plast Surg. 2018 Jan; Eur J Surg Oncol. 2017 Jul;43(7):1236–43.
with or without immediate breast reconstruc- 45(1):33–45. 39 Weber WP, Soysal SD, Zeindler J, Kappos EA,
tion in women unsuitable for standard breast- 26 Bhattacharya IS, Haviland JS, Kirby AM, Kir- Babst D, Schwab F, et al. Current standards in
conserving surgery (the ANTHEM Feasibility wan CC, Hopwood P, Yarnold JR, IMPORT oncoplastic breast conserving surgery. Breast.
Study). BMJ Open. 2021 Apr 16; 11(4): Trialists, et al. Patient-Reported Outcomes 2017 Aug;34(Suppl 1):S78–81.
e046622. Over 5 Years After Whole- or Partial-Breast 40 Weber WP, Soysal SD, El-Tamer M, Sacchini
13 Clough KB, Cuminet J, Fitoussi A, Nos C, Radiotherapy: Longitudinal Analysis of the V, Knauer M, Tausch C, et al. First interna-
Mosseri V. Cosmetic sequelae after conserva- IMPORT LOW (CRUK/06/003) Phase III tional consensus conference on standardiza-
tive treatment for breast cancer: classification Randomized Controlled Trial. J Clin Oncol. tion of oncoplastic breast conserving surgery.
and results of surgical correction. Ann Plast 2019 Feb 1;37(4):305–17. Breast Cancer Res Treat. 2017 Aug; 165(1):
Surg. 1998 Nov;41(5):471–81. 27 Hopwood P, Haviland JS, Sumo G, Mills J, 139–49.
14 Audretsch W, Rezai M, Kolotas C, Zambo- Bliss JM, Yarnold JR, START Trial Manage- 41 Kaufman CS. Increasing Role of Oncoplastic
glou N, Schnabel T, Bojar H. Tumor-specific ment Group. Comparison of patient-reported Surgery for Breast Cancer. Curr Oncol Rep.
immediate reconstruction in breast cancer breast, arm, and shoulder symptoms and body 2019 Dec;21(12):111.
patients. Semin Plast Surg. 1998; 11(01): 71– image after radiotherapy for early breast can- 42 Franceschini G, Terribile D, Magno S, Fabbri
100. cer: 5-year follow-up in the randomised Stan- C, Accetta C, Di Leone A, et al. Update on
15 Clough KB, Nos C, Salmon RJ, Soussaline M, dardisation of Breast Radiotherapy (START) oncoplastic breast surgery. Eur Rev Med
Durand JC. Conservative treatment of breast trials. Lancet Oncol. 2010;11(3):231–40. Pharmacol Sci. 2012 Oct;16(11):1530–40. .
cancers by mammaplasty and irradiation: a 28 Mukesh MB, Qian W, Wilkinson JS, Dorling 43 Noguchi M, Yokoi-Noguchi M, Ohno Y, Mo-
new approach to lower quadrant tumors. L, Barnett GC, Moody AM, et al. Patient re- rioka E, Nakano Y, Kosaka T, et al. Oncoplas-
Plast Reconstr Surg. 1995 Aug;96(2):363–70. ported outcome measures (PROMs) follow- tic breast conserving surgery: Volume re-
16 Galimberti V, Zurrida S, Zanini V, Callegari ing forward planned field-in field IMRT: re- placement vs. volume displacement. Eur J
M, Veronesi P, Catania S, et al. Central small sults from the Cambridge Breast IMRT trial. Surg Oncol. 2016 Jul;42(7):926–34.
size breast cancer: how to overcome the prob- Radiother Oncol. 2014 May;111(2):270–5. 44 Shao J, Rodrigues M, Corter AL, Baxter NN.
lem of nipple and areola involvement. Eur J 29 Tenofsky PL, Dowell P, Topalovski T, Helmer Multidisciplinary care of breast cancer pa-
Cancer. 1993;29A(8):1093–6. SD. Surgical, oncologic, and cosmetic differ- tients: a scoping review of multidisciplinary
17 Clough KB, Kaufman GJ, Nos C, Buccimazza ences between oncoplastic and nononcoplas- styles, processes, and outcomes. Curr Oncol.
I, Sarfati IM. Improving breast cancer sur- tic breast conserving surgery in breast cancer 2019 Jun;26(3):e385–97.
gery: a classification and quadrant per quad- patients. Am J Surg. 2014 Mar; 207(3): 398– 45 Wyld L, Rubio IT, Kovacs T. Education and
rant atlas for oncoplastic surgery. Ann Surg 402; discussion 402. Training in Breast Cancer Surgery in Europe.
Oncol. 2010 May;17(5):1375–91. 30 Piper M, Peled AW, Sbitany H. Oncoplastic Breast Care (Basel). 2019 Dec;14(6):366–72.
18 Anderson BO, Masetti R, Silverstein MJ. On- breast surgery: current strategies. Gland Surg. 46 Kovacs T, Rubio IT, Markopoulos C, Audisio
coplastic approaches to partial mastectomy: 2015 Apr;4(2):154–63. RA, Knox S, Kühn T, BRESO Structure Work-
an overview of volume-displacement tech- 31 Crown A, Laskin R, Rocha FG, Grumley J. Ex- ing Group, et al. Theoretical and practical
niques. Lancet Oncol. 2005 Mar;6(3):145–57. treme oncoplasty: Expanding indications for knowledge curriculum for European Breast
breast conservation. Am J Surg. 2019 May; Surgeons. Eur J Surg Oncol. 2020 Apr;46(4 Pt
217(5):851–6. B):717–36.

Innovative Standards in Oncoplastic Breast Care 2021;16:559–573 571

Breast Conserving Surgery DOI: 10.1159/000518992
47 Losken A, Chatterjee A. Improving Results in 62 Carter SA, Lyons GR, Kuerer HM, Bassett RL 75 Cardoso MJ, Cardoso JS, Vrieling C, Macmil-
Oncoplastic Surgery. Plast Reconstr Surg. Jr, Oates S, Thompson A, et al. Operative and lan D, Rainsbury D, Heil J, et al. Recommen-
2021 Jan 1;147(1):123e–34e. Oncologic Outcomes in 9861 Patients with dations for the aesthetic evaluation of breast
48 Smith ML, Molina BJ, Dayan E, Jablonka EM, Operable Breast Cancer: Single-Institution cancer conservative treatment. Breast Cancer
Okwali M, Kim JN, et al. Defining the Role of Analysis of Breast Conservation with Onco- Res Treat. 2012 Oct;135(3):629–37.
Free Flaps in Partial Breast Reconstruction. J plastic Reconstruction. Ann Surg Oncol. 2016 76 Pezner RD, Patterson MP, Hill LR, Vora N,
Reconstr Microsurg. 2018 Mar;34(3):185–92. Oct;23(10):3190–8. Desai KR, Archambeau JO, et al. Breast re-
49 Macmillan RD, McCulley SJ. Oncoplastic 63 De Lorenzi F, Hubner G, Rotmensz N, Bag- traction assessment: an objective evaluation
Breast Surgery: What, When and for Whom? nardi V, Loschi P, Maisonneuve P, et al. On- of cosmetic results of patients treated conser-
Curr Breast Cancer Rep. 2016;8:112–7. cological results of oncoplastic breast-con- vatively for breast cancer. Int J Radiat Oncol
50 Kronowitz SJ, Kuerer HM, Buchholz TA, serving surgery: Long term follow-up of a Biol Phys. 1985 Mar;11(3):575–8.
Valero V, Hunt KK. A management algo- large series at a single institution: a matched- 77 Krois W, Romar AK, Wild T, Dubsky P,
rithm and practical oncoplastic surgical tech- cohort analysis. Eur J Surg Oncol. 2016 Jan; Exner R, Panhofer P, et al. Objective breast
niques for repairing partial mastectomy de- 42(1):71–7. symmetry analysis with the breast analyzing
fects. Plast Reconstr Surg. 2008 Dec; 122(6): 64 Niinikoski L, Leidenius MHK, Vaara P, tool (BAT): improved tool for clinical trials.
1631–47. Voynov A, Heikkilä P, Mattson J, et al. Resec- Breast Cancer Res Treat. 2017 Jul;164(2):421–
51 Patel K, Bloom J, Nardello S, Cohen S, Reiland tion margins and local recurrences in breast 7.
J, Chatterjee A. An Oncoplastic Surgery Prim- cancer: Comparison between conventional 78 Cardoso MJ, Cardoso J, Amaral N, Azevedo I,
er: Common Indications, Techniques, and and oncoplastic breast conserving surgery. Barreau L, Bernardo M, et al. Turning subjec-
Complications in Level 1 and 2 Volume Dis- Eur J Surg Oncol. 2019 Jun;45(6):976–82. tive into objective: the BCCT.core software
placement Oncoplastic Surgery. Ann Surg 65 Oberhauser I, Zeindler J, Ritter M, Levy J, for evaluation of cosmetic results in breast
Oncol. 2019 Oct;26(10):3063–70. Montagna G, Mechera R, et al. Impact of On- cancer conservative treatment. Breast. 2007
52 Galimberti V, Zurrida S, Zanini V, Callegari coplastic Breast Surgery on Rate of Complica- Oct;16(5):456–61.
M, Veronesi P, Catania S, et al. Central small tions, Time to Adjuvant Treatment, and Risk 79 Moyer HR, Carlson GW, Styblo TM, Losken
size breast cancer: how to overcome the prob- of Recurrence. Breast Care. 2020. A. Three-dimensional digital evaluation of
lem of nipple and areola involvement. Eur J 66 Clough KB, van la Parra RFD, Thygesen HH, breast symmetry after breast conservation
Cancer. 1993;29A(8):1093–6. Levy E, Russ E, Halabi NM, et al. Long-term therapy. J Am Coll Surg. 2008 Aug; 207(2):
53 Benelli L. A new periareolar mammaplasty: Results After Oncoplastic Surgery for Breast 227–32.
the "round block" technique. Aesthetic Plast Cancer: A 10-year Follow-up. Ann Surg. 2018 80 Veiga DF, Veiga-Filho J, Ribeiro LM, Archan-
Surg. 1990 Spring;14(2):93–100. Jul;268(1):165–71. gelo-Junior I, Mendes DA, Andrade VO, et al.
54 McCulley SJ, Macmillan RD, Rasheed T. 67 Piper ML, Esserman LJ, Sbitany H, Peled AW. Evaluations of aesthetic outcomes of onco-
Transverse Upper Gracilis (TUG) flap for vol- Outcomes Following Oncoplastic Reduction plastic surgery by surgeons of different gen-
ume replacement in breast conserving sur- Mammoplasty: A Systematic Review. Ann der and specialty: a prospective controlled
gery for medial breast tumours in small to me- Plast Surg. 2016 May;76(Suppl 3):S222–6. study. Breast. 2011 Oct;20(5):407–12.
dium sized breasts. J Plast Reconstr Aesthet 68 De La Cruz L, Blankenship SA, Chatterjee A, 81 Park CC, Mitsumori M, Nixon A, Recht A,
Surg. 2011 Aug;64(8):1056–60. Geha R, Nocera N, Czerniecki BJ, et al. Out- Connolly J, Gelman R, et al. Outcome at 8
55 Saini KS, Taylor C, Ramirez AJ, Palmieri C, comes After Oncoplastic Breast-Conserving years after breast-conserving surgery and ra-
Gunnarsson U, Schmoll HJ, et al. Role of the Surgery in Breast Cancer Patients: A System- diation therapy for invasive breast cancer: in-
multidisciplinary team in breast cancer man- atic Literature Review. Ann Surg Oncol. 2016 fluence of margin status and systemic therapy
agement: results from a large international Oct;23(10):3247–58. on local recurrence. J Clin Oncol. 2000 Apr;
survey involving 39 countries. Ann Oncol. 69 Losken A, Dugal CS, Styblo TM, Carlson GW. 18(8):1668–75. al
2012 Apr;23(4):853–9. A meta-analysis comparing breast conserva- 82 Pukancsik D, Kelemen P, Újhelyi M, Kovács
56 Kesson EM, Allardice GM, George WD, tion therapy alone to the oncoplastic tech- E, Udvarhelyi N, Mészáros N, et al. Objective
Burns HJ, Morrison DS. Effects of multidisci- nique. Ann Plast Surg. 2014 Feb;72(2):145–9. decision making between conventional and
plinary team working on breast cancer sur- 70 Kosasih S, Tayeh S, Mokbel K, Kasem A. Is oncoplastic breast-conserving surgery or
vival: retrospective, comparative, interven- oncoplastic breast conserving surgery onco- mastectomy: An aesthetic and functional pro-
tional cohort study of 13 722 women. BMJ. logically safe? A meta-analysis of 18,103 pa- spective cohort study. Eur J Surg Oncol. 2017
2012 Apr 26;344:e2718. tients. Am J Surg. 2020 Aug;220(2):385–92. Feb;43(2):303–10.
57 Biganzoli L, Cardoso F, Beishon M, Cameron 71 Yiannakopoulou EC, Mathelin C. Oncoplas- 83 Clough KB, Lewis JS, Couturaud B, Fitoussi
D, Cataliotti L, Coles CE, et al. The require- tic breast conserving surgery and oncological A, Nos C, Falcou MC. Oncoplastic techniques
ments of a specialist breast centre. Breast. outcome: Systematic review. Eur J Surg On- allow extensive resections for breast-conserv-
2020 Jun;51:65–84. col. 2016 May;42(5):625–30. ing therapy of breast carcinomas. Ann Surg.
58 Savalia NB, Silverstein MJ. Oncoplastic breast 72 Mazouni C, Naveau A, Kane A, Dunant A, 2003 Jan;237(1):26–34.
reconstruction: Patient selection and surgical Garbay JR, Leymarie N, et al. The role of on- 84 Tevis SE, James TA, Kuerer HM, Pusic AL,
techniques. J Surg Oncol. 2016 Jun; 113(8): coplastic breast surgery in the management of Yao KA, Merlino J, et al. Patient-Reported
875–82. breast cancer treated with primary chemo- Outcomes for Breast Cancer. Ann Surg On-
59 Silverstein MJ, Mai T, Savalia N, Vaince F, therapy. Breast. 2013 Dec;22(6):1189–93. col. 2018 Oct;25(10):2839–45.
Guerra L. Oncoplastic breast conservation 73 Broecker JS, Hart AM, Styblo TM, Losken A. 85 Weber WP, Morrow M, Boniface J, Pusic A,
surgery: the new paradigm. J Surg Oncol. Neoadjuvant Therapy Combined With On- Montagna G, Kappos EA, et al. Oncoplastic
2014 Jul;110(1):82–9. coplastic Reduction for High-Stage Breast Breast Consortium. Knowledge gaps in onco-
60 Yoon JJ, Green WR, Kim S, Kearney T, Haffty Cancer Patients. Ann Plast Surg. 2017 Jun; plastic breast surgery. Lancet Oncol. 2020;
BG, Eladoumikdachi F, et al. Oncoplastic 78(6S Suppl 5):S258–62. 21(8):e375–e385.
breast surgery in the setting of breast-con- 74 Papanikolaou IG, Dimitrakakis C, Zagouri F, 86 Rendell V, Schmocker R, Abbott DE. Expand-
serving therapy: A systematic review. Adv Ra- Marinopoulos S, Giannos A, Zografos E, et al. ing the Scope of Evidence-Based Cancer Care.
diat Oncol. 2016 Sep;1(4):205–15. Paving the way for changing perceptions in Surg Oncol Clin N Am. 2018 Oct;27(4): 727–
61 Urban C, Anselmi KF, Kroda F, Schwartz JC. breast surgery: a systematic literature review 43.
Oncoplasty as the standard of care in breast focused on oncological and aesthetic out- 87 Pusic AL, Klassen AF, Scott AM, Klok JA,
cancer surgery. Eur Oncol Haematol. 2014; comes of oncoplastic surgery for breast can- Cordeiro PG, Cano SJ. Development of a new
10(1):43–7. cer. Breast Cancer. 2019 Jul;26(4):416–27. patient-reported outcome measure for breast
surgery: the BREAST-Q. Plast Reconstr Surg.
2009 Aug;124(2):345–53.

572 Breast Care 2021;16:559–573 Karadeniz Cakmak

DOI: 10.1159/000518992
88 Mundy LR, Homa K, Klassen AF, Pusic AL, 100 Crown A, Wechter DG, Grumley JW. Onco- 112 Huang J, Barbera L, Brouwers M, Browman
Kerrigan CL. Breast Cancer and Reconstruc- plastic Breast-Conserving Surgery Reduces G, Mackillop WJ. Does delay in starting
tion: Normative Data for Interpreting the Mastectomy and Postoperative Re-excision treatment affect the outcomes of radiother-
BREAST-Q. Plast Reconstr Surg. 2017 May; Rates. Ann Surg Oncol. 2015 Oct; 22(10): apy? A systematic review. J Clin Oncol. 2003
139(5):1046e–55e. 3363–8. Feb 1; 21(3): 555–63. Erratum in: J Clin On-
89 Aaronson NK, Ahmedzai S, Bergman B, Bull- 101 Kronowitz SJ, Feledy JA, Hunt KK, Kuerer col. 2003 Apr;21(7):1424.
inger M, Cull A, Duez NJ, et al. The European HM, Youssef A, Koutz CA, et al. Determin- 113 Losken A, Schaefer TG, Newell M, Styblo
Organization for Research and Treatment of ing the optimal approach to breast recon- TM. The impact of partial breast reconstruc-
Cancer QLQ-C30: a quality-of-life instru- struction after partial mastectomy. Plast Re- tion using reduction techniques on postop-
ment for use in international clinical trials in constr Surg. 2006 Jan;117(1):1–4. discussion erative cancer surveillance. Plast Reconstr
oncology. J Natl Cancer Inst. 1993 Mar 3; 12-4. Surg. 2009 Jul;124(1):9–17.
85(5):365–76. 102 Munhoz AM, Montag E, Arruda EG, Ald- 114 Piper M, Peled AW, Sbitany H, Foster RD,
90 Sprangers MA, Groenvold M, Arraras JI, righi C, Gemperli R, Aldrighi JM, et al. Crit- Esserman LJ, Price ER. Comparison of
Franklin J, te Velde A, au M, et al. The Euro- ical analysis of reduction mammaplasty Mammographic Findings Following Onco-
pean Organization for Research and Treat- techniques in combination with conserva- plastic Mammoplasty and Lumpectomy
ment of Cancer breast cancer-specific quality- tive breast surgery for early breast cancer Without Reconstruction. Ann Surg Oncol.
of-life questionnaire module: first results treatment. Plast Reconstr Surg. 2006 Apr; 2016 Jan;23(1):65–71.
from a three-country field study. J Clin Oncol. 117(4):1091–7; discussion 1104-7. 115 Losken A, Hart AM, Chatterjee A. Updated
1996 Oct;14(10):2756–68. 103 Munhoz AM, Montag E, Fels KW, Arruda Evidence on the Oncoplastic Approach to
91 Sprangers MA, Cull A, Groenvold M, Bjordal EG, Sturtz GP, Aldrighi C, et al. Outcome Breast Conservation Therapy. Plast Recon-
K, Blazeby J, Aaronson NK. The European analysis of breast-conservation surgery and str Surg. 2017 Nov; 140(5S Advances in
Organization for Research and Treatment of immediate latissimus dorsi flap reconstruc- Breast Reconstruction):14S–22S.
Cancer approach to developing questionnaire tion in patients with T1 to T2 breast cancer. 116 Dolan R, Patel M, Weiler-Mithoff E, Mansell
modules: an update and overview. EORTC Plast Reconstr Surg. 2005 Sep; 116(3): 741– J, Stallard S, Doughty JC, et al. Imaging Re-
Quality of Life Study Group. Qual Life Res. 52. sults Following Oncoplastic and Standard
1998 May;7(4):291–300. 104 Hamdi M, Van Landuyt K, Monstrey S, Breast Conserving Surgery. Breast Care (Ba-
92 Char S, Bloom JA, Erlichman Z, Jonczyk MM, Blondeel P. Pedicled perforator flaps in sel). 2015 Oct;10(5):325–9.
Chatterjee A. A comprehensive literature re- breast reconstruction: a new concept. Br J 117 Tasdöven I, Karadeniz Çakmak G, Emre
view of patient-reported outcome measures Plast Surg. 2004 Sep;57(6):531–9. AU, Engin H, Bahadır B, Bakkal HB, et al.
(PROMs) among common breast reconstruc- 105 Landercasper J, Bennie B, Ahmad HF, Line- Intraoperative ultrasonography-guided sur-
tion options: What types of breast reconstruc- barger JH. Opportunities to reduce reopera- gery: An effective modality for breast con-
tion score well? Breast J. 2021 Apr;27(4):322–9. tions and to improve inter-facility profiling servation after neo-adjuvant chemotherapy.
93 Aristokleous I, Saddiq M. Quality of life after after initial breast-conserving surgery for Breast J. 2020 Sep;26(9):1680–7.
oncoplastic breast-conserving surgery: a sys- cancer. A report from the NCDB. Eur J Surg 118 Karadeniz Cakmak G, Emre AU, Tascilar O,
tematic review. ANZ J Surg. 2019 Jun; 89(6): Oncol. 2019;45:2026–36. Bahadir B, Ozkan S. Surgeon performed
639–46. 106 Biganzoli L, Marotti L, Hart CD, Cataliotti L, continuous intraoperative ultrasound guid-
94 Gardfjell A, Dahlbäck C, Åhsberg K. Patient Cutuli B, Kühn T, et al. Quality indicators in ance decreases re-excisions and mastectomy
satisfaction after unilateral oncoplastic vol- breast cancer care: An update from the EU- rates in breast cancer. Breast. 2017 Jun; 33:
ume displacement surgery for breast cancer, SOMA working group. Eur J Cancer. 2017 23–8.
evaluated with the BREAST-Q™. World J Surg Nov;86:59–81. 119 Pop FC, Veys I, Vankerckhove S, Barbieux
Oncol. 2019 Jun 5;17(1):96. 107 Kapadia SM, Reitz A, Hart A, Broecker J, R, Chintinne M, Moreau M, et al. Absence of
95 Chand ND, Browne V, Paramanathan N, Pei- Torres MA, Carlson GW, et al. Time to Ra- residual fluorescence in the surgical bed at
ris LJ, Laws SA, Rainsbury RM. Patient-Re- diation After Oncoplastic Reduction. Ann near-infrared fluorescence imaging predicts
ported Outcomes Are Better after Oncoplas- Plast Surg. 2019 Jan;82(1):15–8. negative margins at final pathology in pa-
tic Breast Conservation than after Mastecto- 108 Bartelink H, Horiot JC, Poortmans PM, tients treated with breast-conserving sur-
my and Autologous Reconstruction. Plast Struikmans H, Van den Bogaert W, Four- gery for breast cancer. Eur J Surg Oncol.
Reconstr Surg Glob Open. 2017 Jul 24; 5(7): quet A, et al. Impact of a higher radiation 2021 Feb;47(2):269–75.
e1419. dose on local control and survival in breast- 120 Hwang ES, Lichtensztajn DY, Gomez SL,
96 Kelsall JE, McCulley SJ, Brock L, Akerlund conserving therapy of early breast cancer: Fowble B, Clarke CA. Survival after lumpec-
MTE, Macmillan RD. Comparing oncoplastic 10-year results of the randomized boost ver- tomy and mastectomy for early stage inva-
breast conserving surgery with mastectomy sus no boost EORTC 22881-10882 trial. J sive breast cancer: the effect of age and hor-
and immediate breast reconstruction: Case- Clin Oncol. 2007 Aug 1;25(22):3259–65. mone receptor status. Cancer. 2013 Apr 1;
matched patient reported outcomes. J Plast 109 Romestaing P, Lehingue Y, Carrie C, Co- 119(7):1402–11.
Reconstr Aesthet Surg. 2017 Oct; 70(10): quard R, Montbarbon X, Ardiet JM, et al. 121 Gentilini OD, Cardoso MJ, Poortmans P.
1377–85. Role of a 10-Gy boost in the conservative Less is more. Breast conservation might be
97 Catsman CJLM, Beek MA, Voogd AC, Mul- treatment of early breast cancer: results of a even better than mastectomy in early breast
der PGH, Luiten EJT. The COSMAM TRIAL randomized clinical trial in Lyon, France. J cancer patients. Breast. 2017 Oct;35:32–3.
a prospective cohort study of quality of life Clin Oncol. 1997 Mar;15(3):963–8. 122 van Maaren MC, de Munck L, de Bock GH,
and cosmetic outcome in patients undergoing 110 Thomas K, Rahimi A, Spangler A, Anderson Jobsen JJ, van Dalen T, Linn SC, et al. 10 year
breast conserving surgery. BMC Cancer. 2018 J, Garwood D. Radiation practice patterns survival after breast-conserving surgery plus
Apr;18(1):456. among United States radiation oncologists radiotherapy compared with mastectomy in
98 Haloua MH, Krekel NM, Winters HA, Riet- for postmastectomy breast reconstruction early breast cancer in the Netherlands: a
veld DH, Meijer S, Bloemers FW, et al. A sys- and oncoplastic breast reduction. Pract Ra- population-based study. Lancet Oncol. 2016
tematic review of oncoplastic breast-conserv- diat Oncol. 2014;4:466–71. Aug;17(8):1158–70.
ing surgery: current weaknesses and future 111 Punglia RS, Saito AM, Neville BA, Earle CC, 123 Kuerer HM, Vrancken Peeters MTFD, Rea
prospects. Ann Surg. 2013 Apr; 257(4): 609– Weeks JC. Impact of interval from breast DW, Basik M, De Los Santos J, Heil J. Non-
20. conserving surgery to radiotherapy on local operative Management for Invasive Breast
99 Cardoso JS, Silva W, Cardoso MJ. Evolution, recurrence in older women with breast can- Cancer after Neoadjuvant Systemic Thera-
current challenges, and future possibilities in cer: retrospective cohort analysis. BMJ. 2010 py: Conceptual Basis and Fundamental In-
the objective assessment of aesthetic outcome Mar 2;340:c845. ternational Feasibility Clinical Trials. Ann
of breast cancer locoregional treatment. Surg Oncol. 2017 Oct;24(10):2855–62.
Breast. 2020 Feb;49:123–30.

Innovative Standards in Oncoplastic Breast Care 2021;16:559–573 573

Breast Conserving Surgery DOI: 10.1159/000518992